Frequently Used Forms

Please click on a form below to view a PDF printable version.

Claims
Provider Dispute Resolution Request Form

Prior Authorizations

Behavioral Health Prior Authorization Form
Behavioral Health Therapy Prior Authorization Form (Autism)
Applied Behavior Analysis Referral Form
Q3 2020 PA Code Matrix
Q2 2020 PA Code Matrix
Q1 2020 PA Code Matrix
Q4 2019 PA Code Matrix
Q3 2019 PA Code Matrix
Q2 2019 PA Code Matrix
Q1 2019 PA Code Matrix
Q4 2018 PA Code Matrix
Q3 2018 PA Code Matrix
Q2 2018 PA Code Matrix
Q1 2018 PA Code Matrix
Continuity of Care Form
Prior Authorization 2018 Guide
Prior Authorization 2019 Guide
Prior Authorization 2020 Guide
Prior Authorization 2020 Guide v2

 

Referral Forms
Complex Case Management - External CM Referral Form
Case Management Referral Form

Behavioral Health Coordination of Care Form
Health Education Referral Form [Direct Providers | IPA Medical Group]

Transportation
Physician Certification Statement

Pharmacy
Medical Benefit (HCPCS/J-Code) Drug Prior Authorization Form
Prescription Drug Prior Authorization Request Form

Verio Healthcare Provider Request Forms for DME Equipment and Supplies




Other Forms and Resources
Medi-Cal Non-Covered Services
Member Grievance Form (English)
Member Grievance Form (Spanish)
Member Grievance Form (Arabic)
Member Grievance Form (Chinese)
Member Grievance Form (Hmong)
Member Grievance Form (Russian)
Member Grievance Form (Vietnamese)
Member Grievance Form (Tagalog)



Allowed In-Office Lab Test List, effective 5-15-2018

Contracted Providers Making Changes
Membership Panel Form

Credentialing

 

Health Education Forms

Health Education Referral Form Direct Providers Only
Health Education Referral Form IPA Providers Only
Health Management Services Flyer (for Members only)
Health Education Services Provider Resources Flyer (for Providers only)

 

Cultural & Linguistic Services Forms

Cultural and Linguistic Services - For Providers only
Cultural and Linguistic Services for Members

Staying Healthy Assessment Requirement

This requirement applies to all managed Medi-Cal members.

The initial health assessment includes the Initial Health Education Behavioral Assessment (IHEBA) which utilizes the “Staying Healthy Assessment”(SHA) form. The SHA forms are produced by DHCS and consist of 9 specific age categories (0-6 months, 7-12 months, 1-2 years, 3-4 years, 5-8 years, 9-11 years, 12-17 years, adult and seniors).

The assessment is designed to be completed by members age 12 and over and by parents for ages 11 and under, while waiting for their medical visit. If a member or parent requests help with completion, it must be provided. This assessment is designed to initiate dialogue between member and provider facilitating focused health education counseling addressing health behavior change.

This assessment must be completed with all new members within 120 days of enrollment into the plan. It must also be done with all existing patients at their next non-acute care visit and when entering into a new age category.

Staying Healthy Assessment Resources

  • Click here to view the Staying Healthy Assessment Provider Training video
  • for the Staying Healthy Assessment Training Attestation Sign-in Form

Staying Healthy Assessment Forms (pdf icon)

See links below for Staying Healthy Assessment forms in English, Spanish, Arabic, Farsi, Khmer, Somali, Armenian, Chinese, Hmong, Korean, Russian, Tagalog and Vietnamese

 

If you are unable to access the forms please contact your Provider Services representative.

Alternative Forms or Electronic Formats

If you are planning to use an alternative to the SHA forms and/or converting the SHA forms into an electronic format, please complete the request form below and submit it to Molina at least one month before using the alternative form(s).

SHA Electronic or Other Format Notification Form


Smoking Cessation Resources

Support Groups and Classes
ACOG Guidelines – Smoking Cessation During Pregnancy

 

 

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